Case Presentation: Introduction:Odynophagia can occur from a variety of conditions, most commonly from pharyngitis or esophagitis. Retropharyngeal or deep neck space infections need to be considered when odynophagia is accompanied with decreased ability to move the neck, fevers, and/or elevated white blood cell counts. Here, we present a case of an uncommon condition mimicking a deep neck space infection.
Case:A 45 year old Hispanic female with a past medical history of chronic sinusitis and chronic neck pain from degenerative disc disease presented with a 3 day history of progressively worsening neck pain, odynophagia, bitemporal headache, and transient blurry vision. The neck pain was worse with movement but was not typical of her chronic neck pain. She reported recently completing a 10 day antibiotic course for a sinus infection. She denied any new trauma or strenuous activity prior to onset of this pain. Vital signs showed she was afebrile and otherwise hemodynamically stable. Physical exam revealed tenderness to palpation of the posterolateral neck without swelling or deformity and a normal appearing pharynx without erythema or exudates. Her cervical range of motion was significantly impaired due to pain. Labs revealed a normal WBC count but elevated C-Reactive Protein of 8.9, Erythrocyte Sedimentation Rate of 51. Pharyngeal swabs for streptococcus, gonorrhea, and chlamydia were negative. ANA was negative. CT angiography of her head and neck did not show any arterial dissections or abscess but did show mild retropharyngeal/prevertebral edema with mildly enlarged reactive cervical lymph nodes. Due to concern for a deep neck space infection, she was started on IV Ampicillin/Sulbactam. After 2 days with no improvement, an MRI was obtained. This revealed prevertebral edema from C1-4 with inflammatory changes surrounding the left longus coli muscle and a calcific density within this muscle, confirming the diagnosis of acute calcific longus coli tendinitis. She was started on high dose NSAIDs with gradual improvement and discharged.
Discussion: The Longus colli muscle is a paired muscle located on the anterior aspect of the cervical and first three thoracic vertebrae that is responsible for cervical forward flexion, side bending, and rotation. Acute calcific tendinitis of the longus colli muscle is a rare, self-limiting inflammatory process that often occurs in the 3rd to 6th decade of life. It typically presents with neck pain, headache, low grade fevers, and odynophagia. The pathogenesis involves the deposition of calcium hydroxyapatite crystals on the longus colli muscle, leading to an acute inflammatory response. There is speculation this condition can be precipitated by trauma or upper respiratory illness, such a sinusitis. The temporally located headaches are thought to be related to cervicogenic headaches with referred pain from irritation of the deep neck flexors. The odynophagia is due to the proximity of the pharynx and esophagus to the inflamed muscle. Laboratory values may reveal an elevated erythrocyte sedimentation rate, C-reactive protein, and/or white blood cell count. CT or MRI will typically confirm the diagnosis. The prognosis is good with most cases completely resolving within days to weeks with NSAID treatment as first line therapy.
Conclusions: This case illustrates the importance for clinicians to be aware of this condition when patients present with odynophagia and/or neck pain, as prompt treatment with anti-inflammatories can decrease hospital length of stay and improve patient comfort.